2018 Research Forum

Comparing the use of IV anxiolytics plus standard analgesic care versus standard analgesic care alone in controlling severe, acute pain in the emergency department

Presenter: Andrew C Fischer MD Principal Investigator & Faculty Sponsor: Rick McPheeters DO

Andrew C Fischer MD 1 , Jing Liu MD 1 , Uriel Manzo MD 1 , Wafa Ahmed RA 2 , Laura Castro RA 2 , Rick McPheeters DO 3 1 Resident Physician R4 2 Emergency Medicine Research Assistant Program 3 Chair, Department of Emergency Medicine; Health Sciences Associate Clinical Professor, David Geffen School of Medicine UCLA INTRODUCTION Controlling acute pain remains a common and challenging problem in the emergency department (ED) Undertreating pain can lead to poor patient satisfaction and unnecessary suffering. However excessive analgesic treatment can be dangerous and still does not guarantee that the patient will have satisfactory pain control. In the pediatric, dental, and anesthesia literature combining anxiolytics and opioid analgesics has been shown to control acute pain better than single agent opioids. PURPOSE Our study seeks to determine whether a combined, anxiolytic plus opioid analgesic, treatment offers a clinically significant improvement over the standard of care, analgesic only, treatment for acute pain in the ED. METHOD This is a small sample analysis of an ongoing prospective, single-blinded randomized clinical trial. We enrolled opioid naive patients complaining of severe acute pain 7/10 or higher and then surveyed their pain levels with a 0-10 cm visual analogue scale (VAS) at 30 minutes, 1 hour, 2 hours, and 4 hours after administration of pain medication. A pain level of 4cm or below represented successful control of pain. The intervention group received both an IV standard 2 mg dosage of the anxiolytic midazolam and a standard analgesic dosage of 0.1 mg per kg of IV morphine while the control group only received morphine per standard of care. The number of patient requests for additional morphine and the total amount of morphine administered were also tracked for both groups. RESULTS Simple multivariate analysis was performed to analyze the data. There was no significant improvement in pain at 30 minutes, 1 hour, 2 hour or 4 hours in the control group. However, the intervention group had significant improvement in their pain scores compared to the control group at all time intervals (P < 0.05, n=28) (Figure 1). Additionally, the control group required more morphine during their ED course and more frequent morphine redosing than the intervention group (P < 0.05). Furthermore, the intervention group had their pain successfully well controlled faster and had a higher proportion of patients with well-controlled pain compared to the control group (Figure 2). Moreover, there were no adverse events with the concomitant administration of midazolam and morphine.

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